Basic Information
| Provider Information | |||||||||
| NPI: | 1114074200 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENTS PATHOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 8556714753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SHIRCLIFF WAY | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087300 | ||||||||
| FaxNumber: | 9043082970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | DESTEPHANO | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | BERNARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9043087300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.